Director of Claims- Healthcare

Director of Claims- Healthcare Preferred IPA of California is committed to delivering exceptional care management, care coordination, and claim processing services that support high-quality healthcare outcomes for members and providers. Working closely with participating physicians, we ensure seamless coordination of patient care while maintaining operational excellence across the network. The Director of Claims is a senior leadership role responsible for the strategic direction, operational management, and regulatory oversight of the Claims Department. This position oversees all aspects of claims administration, including claims adjudication, payment accuracy, delegated claims oversight, regulatory compliance, vendor management, process improvement, and team development. The Claims Director ensures timely, accurate, and compliant claims processing while meeting all applicable DHCS, DMHC, CMS, NCQA, contractual, and health plan requirements, supporting TMS's commitment to service excellence for providers and members. Best-in-Class Benefits and Culture: We value our employees’ time and efforts. Our commitment to your success is enhanced by competitive compensation of $130,000 - $160,000 annually, depending on experience, and an extensive benefits package including: Comprehensive health coverage: Medical, dental, and vision insurance provided Robust retirement planning: 401(k) plan available with employer matching Financial security: Life and disability insurance for added protection Flexible financial options: Health savings and flexible spending accounts offered Well-being and work-life balance: Paid time off, flexible schedule, and remote work one day per week Plus, we work to maintain the best environment for our employees, where people can learn and grow with the company. We strive to provide a collaborative, creative environment where everyone feels encouraged to contribute to our processes, decisions, planning, and culture. To thrive as the Director of Claims, you should have: Bachelor's degree in Healthcare Administration, Business Administration, Finance, or a related field preferred, with extensive managed care claims experience considered in lieu of formal education. Minimum of 7 to 10 years of progressively responsible managed care claims experience, including at least 5 years in a leadership role overseeing claims operations. Strong knowledge of Medicare and Medi-Cal managed care claims processing, reimbursement methodologies, and regulatory requirements, including DHCS, DMHC, CMS, and NCQA standards. Demonstrated experience interpreting regulatory and health plan requirements and implementing operational changes affecting claims processes, benefit configurations, payment methodologies, and workflows. Proven expertise in claims oversight, including delegation audits, corrective action planning, claims trend analysis, payment variance monitoring, and identification of recovery and process improvement opportunities. Ready to make your mark in healthcare? Join a mission-driven organization dedicated to improving healthcare outcomes for providers and members across California. If you are a strategic, results-oriented claims leader with a passion for operational excellence, regulatory compliance, and team development, we invite you to apply and help shape the future of claims management at Preferred IPA of California. We are an equal opportunity employer that welcomes and encourages diversity in the workplace. We do not discriminate based on race, color, religion, marital status, age, national origin, ancestry, physical or